MEDICAL HISTORY• U.S. 28 year old male, catholic, married, born

on May 6, 1981, works as a tricycle driver since 2001, residing in Caloocan City with wife.

• Chief Complaint:

History of Present Illness

7 Yrs PTA

•White scales of the scalp resembled dandruff when scratched (no consult)• Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face consult at UST Dermatology OPD; punch biopsy: Psoriasis – medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn resolution of Symptoms

•White scales of the scalp resembled dandruff when scratched (no consult)• Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face consult at UST Dermatology OPD; punch biopsy: Psoriasis – medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn resolution of Symptoms

2 Yrs PTA

• Reappearance of lesions • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen temporary relief)• Gradual limitation of in the movement of digits• Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up

• Reappearance of lesions • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen temporary relief)• Gradual limitation of in the movement of digits• Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up

1 Yr PTA• Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs• Relieved by rest or sitting down

• Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs• Relieved by rest or sitting down

1 month PTA • Swelling of both knees with increasing severity of pain (no consult)• Swelling of both knees with increasing severity of pain (no consult)

1 week PTA • Pain in the hips extending down to his ankles• More difficulty in ambulating• Pain in the hips extending down to his ankles• More difficulty in ambulating

5 days PTA• Consulted an Orthopedic Surgeon in Marikina; was told to have excess fluid in knee joints & advised arthrocentesis (pt. opted not to)

• Consulted an Orthopedic Surgeon in Marikina; was told to have excess fluid in knee joints & advised arthrocentesis (pt. opted not to)

4 days PTA

•Fever [undocumented] (self-medication: Paracetamol temporary lysis of fever)• Persistence of pain and fever consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management

•Fever [undocumented] (self-medication: Paracetamol temporary lysis of fever)• Persistence of pain and fever consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management

ADMISSION

Past Medical History

• (-) DM• (-) HPN• (-) Joint surgery• (-) history of trauma• (-) Allergy• Diagnosed with dengue fever (2nd year high

school)• Excision of cyst at the back (2007)

Family History

• (+) Myocardial Infarction – father• (+) DM – father• (-) HPN• (-) stroke• (-) Psoriasis• (-) Cancer• (-) Arthrides

Personal & Social History

• Smoker: 16-22 y/o (1-2 sticks per day)• Occasional Alcoholic Beverage Drinker• Denies Illicit Drug Use• 3 past sexual partners, all protected

Review of Systems

• No wt. loss, no loss of appetite• No hearing loss, no nasal congestion, no

cough• No dyspnea, orthopnea, cyanosis• No chest pain, palpitations• No abdominal pain, diarrhea, constipation• No dysuria, frequency, change in character of

urine

PHYSICAL EXAMINATION

General Survey• Conscious, coherent, oriented as to time, place and

person, not in cardio-respiratory distressVital Signs• BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6 °CSkin• Warm moist skin, (+) erythematous plaques topped

with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy

HEENT• Pink palpebral conjunctivae, anicteric sclerae, no naso-

aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged

Neck• Supple neck, trachea midline, no palpable cervical lymph

nodes, thyroid gland not enlargedCardiovascular• Adynamic precordium, AB at 5th LICS, MCL; no murmurs• All pulses full and equalRespiratory• Symmetric chest expansion, no retractions, clear breath

sounds on all lung fields, no crackles, no wheezes

Abdomen• Flat abdomen, NABS, soft, nontender, no

massesMusculoskeletal• (+) sausage-shaped 4th digit of the right hand• (+) swelling and tenderness, both knees, DIP

4th R digit of the hand, R ankle• (+) flexed 5th left digit and the 4th R digit of the

hand• Cannot flex the PIP and DIP of the right 2nd

digit of the hand

Neurological• Conscious, oriented to person, place and time,

can follow commands• GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL,

V1,V2,V3 intact; intact hearing, can swallow, (+) gag reflex, can shrug shoulders, tongue midline on protrusion

• Motor: MMT 5/5 on both UE; 4/5 on both LE, no atrophy

• Cerebellum: no deficits, can do FTNT, APST, HTST• Sensory: no sensory deficits• DTRs: 2+ on the UE, LE not assessed• (-) Babinski; no nuchal rigidity

SALIENT FEATURES• History of Psoriasis• Painful swelling of distal and proximal joints of

the fingers of right and left hands and feet• Gradual limitation of in the movement of digits• Pain and swelling in both knees (increasing

severity of pain), limping, and pain when walking down the stairs (difficulty in ambulating); Relieved by rest or sitting down

• Pain in the hips extending down to ankle• excess fluid in knee joints• Persistence of pain and fever• X-ray of leg: soft tissue swelling

SALIENT FEATURES• (+) erythematous plaques topped with scales

all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy

• (+) sausage-shaped 4th digit of the right hand• (+) swelling and tenderness, both knees, DIP

4th R digit of the hand, R ankle• (+) flexed 5th left digit and the 4th R digit of the

hand• Cannot flex the PIP and DIP of the right 2nd

digit of the hand